Intestinal failure (IF) is a debilitating condition of inadequate nutrition due to an anatomical and/or physiological deficit of the intestine. Surgical management of patients with acute and chronic IF requires expertise to deal with technical challenges and make correct decisions. Dedicated IF units have expertise in patient selection, operative risk assessment and multidisciplinary support such as nutritional input and interventional radiology, which dramatically improve the morbidity and mortality of this complex condition and can beneficially affect the continuing dependence on parenteral nutritional support. Currently there is little guidance to bridge the gap between general surgeons and specialist IF surgeons. Fifteen European experts took part in a consensus process to develop guidance to support surgeons in the management of patients with IF. Based on a systematic literature review, statements were prepared for a modified Delphi process. The evidence for each statement was graded using Oxford Centre for Evidence-Based Medicine Levels of Evidence. The current paper contains the statements reflecting the position and practice of leading European experts in IF encompassing the general definition of IF surgery and organization of an IF unit, strategies to prevent IF, management of acute IF, management of wound, fistula and stoma, rehabilitation, intestinal and abdominal reconstruction, criteria for referral to a specialist unit and intestinal transplantation.
Objective: Primary hyperparathyroidism (pHPT) is characterised by an inappropriate over production of parathyroid hormone and it is the most frequent pathological condition of the parathyroid glands. A minority of the cases belong to familial forms, but most of them are sporadic. The genetic alterations underlying the sporadic forms of pHPT remain poorly understood. The main goal of our study is to perform the molecular characterisation of a series of sporadic pHPT cases. Design and methods: We have studied matched blood and tumour from 24 patients with pHPT, who went to a medical appointment in Hospital Pedro Hispano. Informed consent was obtained from all individuals. The MEN1, RET and CDKN1B molecular study was carried out in the germline DNA by PCR/SSCP and direct sequencing. Parathyroid tumours were further analysed by the same methods for MEN1, CDKN1B and CTNNB1 genetic alterations. The multiplex ligation-dependent probe amplification technique enabled the evaluation of MEN1 gene deletions. Protein expression for menin, cyclin D1, parafibromin, p27Kip1 , b-catenin and Ki-67 was conducted by immunohistochemistry. Results: The study of parathyroid tumours detected two somatic MEN1 mutations (c.249_252delGTCT and c.115_163del49bp) and revealed the presence of MEN1 intragenic deletions in 54% (13/24) of the tumours. In RET and CDKN1B genes only previously described, non-pathogenic variants were found. Cyclin D1 protein was overexpressed in 13% (3/24) of tumours. Conclusions: These results suggest that MEN1 alterations, remarkably intragenic deletions, may represent the most prevalent genetic alteration in sporadic parathyroid tumours.
MUSEC is an effective and original educational format, enjoyed by candidates, that fills an educational gap for tailored US education as a procedural skill to acute care surgeons. Ongoing revisions should reduce the current limitations and increase the educational value, in terms of number of modules and post-course credentialing.
Highlights Coloovarian fistula can complicate acute colonic diverticulitis. Gas and liquid in the ovary on CT scan suggests the presence of a fistulous tract. Conservative treatment with or without drainage should be the first approach. En bloc resection with primary anastomosis is feasible.
Dieulafoy's lesions are rare and usually present in the stomach. There are only 18 cases of jejunal Dieulafoy's lesion reported. It can present as a massive gastrointestinal bleed and a high grade of suspicion is necessary for a quick and effective approach. The authors present the case of a 14-year-old adolescent with a sudden onset of hematochezia and shock. The high and low endoscopies as well as the arteriography were all inconclusive. An exploratory laparotomy was undertaken in the first 24 h of hospital admission. A review of the small bowel by advancing soft bowel clamps in a sequential manner revealed a bleeding lesion in the jejunum. The histological exam showed a Dieulafoy's lesion.
The last decade was marked by a multiplication in the number of publications on (and usage of) the concept of damage control laparotomy, resulting in a growing number of patients left with an open abdomen (or peritoneostomy). Gigantic hernias are among the dreaded consequences of damage control and the impossibility of closing the abdomen during the initial hospital admission. To minimize this sequela, the literature has proposed many different strategies. In order to explore this topic, the "Evidence-based Telemedicine - Trauma & Acute Care Surgery" (EBT -TACS) conducted a literature review and critically appraised the most relevant articles on the topic. No commercially available systems for the closure of peritoneostomies were analyzed, except for negative pressure therapy. Three relevant and recently published studies on the sequential closure of the abdominal wall (with mesh or sutures) plus negative pressure therapy were appraised. For this appraisal 2 retrospective and one prospective study were included. The EBT-TACS meeting was attended by representatives of 6 Universities and following recommendations were generated: (1) the association of negative pressure therapy and continuous fascia traction with mesh or suture and adjusted periodically appears to be a viable surgical strategy to treat peritoneostomies. (2) the primary dynamic abdominal closure with sutures or mesh appears to be more efficient and economically sound than leaving the patient with a gigantic hernia to undergo complex repair at a later date. New studies including larger number of patients classified according to their different presentations and diseases are needed to better define the best surgical treatment for patients with peritoneostomies.
Laparoscopy has been studied as an alternative to laparotomy in colorectal cancer treatment. This retrospective study analyzed postoperative and 2-year oncological outcomes of 205 patients who underwent surgery for colorectal cancer in a Portuguese center. There were no major significant differences between patients submitted to laparoscopy or laparotomy. Operating time was significantly shorter and length of stay significantly longer with laparotomy (135.09 vs 189.29 min [p < 0.001]; 20.32 vs 11.44 days [p < 0.001]). Mean 2-year survival was not significantly different between laparoscopy and laparotomy (overall: 1.96 vs 1.96 [p = 0.866]; disease-free: 1.93 vs 1.89 [p = 0.411]). Port-site metastasis prevalence was 1.56%. In this retrospective study, laparoscopy showed its noninferiority in colorectal cancer treatment, although it should be complemented by controlled prospective studies.
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